Understanding Migraine Treatment in the Emergency Room

What patients can expect in the ER and how can they can advocate for better treatment and care

Patients with migraine who begin to experience severe and unusual symptoms should visit the ER to get treatment and seek relief from their symptoms. However, ER physicians do not specialize in headache medicine, so the medication and treatment they provide may not be as effective as a trip to a neurologist or headache specialist. Dr. Katherine Hamilton, Headache Fellow at the Montefiore Headache Center, explains when is the appropriate time for patients with migraine to go to the ER and what they can expect there.

Why Patients with Migraine Go to the ER

“The most common reason is actually concern that there is a serious underlying cause such as a hemorrhage, stroke, brain tumor, or infection,” said Dr. Hamilton. “Another common reason that patients go to the emergency room with migraine is that the pain has just become so severe and difficult to treat at home that they need stronger treatments that can be administered in the emergency room.”

Go to the ER if you are experiencing severe migraine symptoms, or symptoms such as confusion, fever and vision changes, neck stiffness, trouble speaking or numbness or weakness, even if other symptoms of migraine are present (e.g. light sensitivity, nausea). Always go to the ER if a headache begins suddenly and reaches maximum intensity within a minute or two. If you recognize your symptoms as those of a typical migraine attack, you may be better served to treat yourself at home, based on the treatment plan you and your headache specialist have drafted together. If you don’t’ have a rescue plan, then speak with your physician to develop one so that you can avoid going into the ER. A trip to the ER may even exacerbate a migraine or provide only temporary relief – only to have the pain roaring back within hours after leaving the ER.

Challenges Patients with Migraine Face in the ER

“The emergency room can be a really challenging place for a patient with a migraine,” said Dr. Hamilton. “It’s a chaotic environment with noise, bright lights, odors which may be offensive – it’s sensory overload – the very last thing a patient in the midst of a migraine attack needs or wants.”

In the emergency room, people with migraine face unique challenges. ER doctors approach neurological problems with caution, so people with migraine should generally expect testing, including CT scans, and possibly a spinal tap (lumbar puncture). Patients are likely seeing new doctors who don’t know their medical history and what generally works best for them, which can lead to less effective treatment. Opioids and narcotics are commonly prescribed to patients with migraine, even though they’re not as effective as other alternatives, and come with risks.

“Migraine is often not recognized as a serious problem in the emergency department and patients may not get the attention that is expected or deserved,” said Dr. Hamilton.

How Patients Can Advocate for Their Care in the ER

“Know your migraine and know which treatments have worked for you in the past,” said Dr. Hamilton. “Especially if you’ve been to the emergency room before, it can be very helpful to come up with a plan of attack for what you should do if there is a next time that you have to go.”

She suggests that patients work with their neurologist or headache specialist to figure out a rescue plan designed to keep patients out of the ER. When the rescue options fail, work with your doctor and draft a treatment plan that is then signed by the doctor. This is helpful when it’s hard for patients to think straight and fully communicate during an attack.

“I think we could potentially lower the number of people who are going to the emergency room if you know exactly when to be concerned and if you have a rescue or backup plan if your usual treatments don’t work,” said Dr. Hamilton.

The American Migraine Foundation has an extensive collection of information related to migraine and headache disorder in the emergency room. Find more information in our Resource Library, and use the Find a Doctor database to connect with a specialist near you.